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Anesthesiologist- and System-Related Risk Factors for Risk-Adjusted Pediatric Anesthesia-Related Cardiac Arrest
Steven E Zgleszewski1, Dionne A Graham, Paul R Hickey
1From the *Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts; and †Center for Patient Safety and Quality Research, Boston Children's Hospital, Boston, Massachusetts.
Insights
Pediatric anesthesia-related cardiac arrest (ARCA) is rare but preventable. Fewer anesthesiologist days delivering anesthesia increased ARCA risk, even after adjusting for patient severity. Rigorous risk adjustment is crucial in patient safety studies.
Area of Science:
- Anesthesiology
- Pediatric Critical Care
- Patient Safety Research
Background:
- Pediatric anesthesia-related cardiac arrest (ARCA) is an uncommon, potentially preventable adverse event.
- Infants and children with more severe underlying diseases face the highest risk of ARCA.
- Identifying system- and anesthesiologist-related risk factors for ARCA is critical.
Purpose of the Study:
- To identify system- and anesthesiologist-related risk factors for pediatric anesthesia-related cardiac arrest (ARCA).
- To analyze the impact of patient severity and anesthesiologist experience on ARCA risk.
Main Methods:
- Analysis of a prospectively collected cohort of pediatric anesthetics administered between 2000 and 2011.
- Characterization of pre-procedure systemic disease using ASA physical status (ASA-PS).
- Independent review of cardiac arrests to determine anesthesia relatedness and reevaluation of factors after adjustment for patient age and ASA-PS.
Main Results:
- Cardiac arrest occurred in 5.1/10,000 anesthetics; 2.6/10,000 were anesthesia-related.
- Univariate analysis showed higher ARCA risk associated with cardiac patients, lower anesthesiologist caseload, and fewer annual anesthesia days.
- After risk adjustment, only fewer annual anesthesia days remained a significant risk factor for ARCA (P=0.03).
Conclusions:
- Patient case-mix explained most associations between ARCA risk and anesthesiologist variables.
- Fewer annual days delivering anesthetics remained a significant independent risk factor for pediatric ARCA.
- Findings underscore the necessity of rigorous adjustment for patient risk factors in anesthesia patient safety research.
Background:
Pediatric anesthesia-related cardiac arrest (ARCA) is an uncommon but potentially preventable adverse event. Infants and children with more severe underlying disease are at highest risk. We aimed to identify system- and anesthesiologist-related risk factors for ARCA.
Methods:
We analyzed a prospectively collected patient cohort data set of anesthetics administered from 2000 to 2011 to children at a large tertiary pediatric hospital. Pre-procedure systemic disease level was characterized by ASA physical status (ASA-PS). Two reviewers independently reviewed cardiac arrests and categorized their anesthesia relatedness. Factors associated with ARCA in the univariate analyses were identified for reevaluation after adjustment for patient age and ASA-PS.
Results:
Cardiac arrest occurred in 142 of 276,209 anesthetics (incidence 5.1/10,000 anesthetics); 72 (2.6/10,000 anesthetics) were classified as anesthesia-related. In the univariate analyses, risk of ARCA was much higher in cardiac patients and for anesthesiologists with lower annual caseload and/or fewer annual days delivering anesthetics (all P < 0.001). Anesthesiologists with the highest academic rank and years of experience also had higher odds of ARCA (P = 0.02). After risk adjustment for ASA-PS ≥ III and age ≤ 6 months, however, the association with lower annual days delivering anesthetics remained (P = 0.03), but the other factors were no longer significant.
Conclusions:
Case-mix explained most associations between higher risk of pediatric ARCA and anesthesiologist-related variables at our institution, but the association with fewer annual days delivering anesthetics remained. Our findings highlight the need for rigorous adjustment for patient risk factors in anesthesia patient safety studies.
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